Version 4/2021

COVID-19 DECLARATION FORM (HEALTHCARE WORKER)

(Individual facility may amend the form according to the need of local setting)

ANSWER ALL QUESTIONS (TICK √ WHERE APPROPRIATE)

A. EPIDEMIOLOGICAL LINK Yes No
Residing or working in an area/locality with high risk of transmission of virus: closed
1 residential settings, institutional settings such as prisons, immigration detention
depots ; anytime within the 14 days prior to sign and symptom onset
If yes, please specify the area: _________________________________
Residing or travel to an area with community transmission anytime within the 14 days
2 prior to sign and symptom onset
If yes, please specify the area: ________________________________
Working in any health care setting, including within health facilities or within the
3 community; any time within the 14 days prior to sign and symptom onset.
If yes, please specify the health care setting: _____________________
Linked to a COVID-19 cluster within the past 14 days prior to sign and symptom
4
onset.
Close contact to a confirmed case of COVID-19, within 14 days before
5 onset of illness.
If yes, please answer questions a to d:
a. Health care associated exposure without appropriate PPE (including
providing direct care for COVID-19 patients, working with health care
workers infected with COVID-19, visiting patients or staying in the
same close environment of a COVID-19 patient).
b. Working together in close proximity or sharing the same classroom environment
with a with COVID-19 patient
c. Traveling together with COVID-19 patient in any kind of conveyance
d. Living in the same household as a COVID-19 patient

B. SYMPTOMS
Yes No Yes No
1 Fever 8 Dyspnea
2 Cough 9 Anorexia / Nausea / Vomiting
3 General weakness /Fatigue 10 Diarrhea
4 Headache 11 Altered mental status
5 Myalgia 12 Sudden loss of smell (Anosmia)
6 Sore throat 13 Sudden loss of taste (Argeusia)
7 Coryza ___________0C
TEMPERATURE

Signature of Healthcare Worker: Signature of Screening Officer:

Name: _________________________ Name: _________________________

IC Number: _____________________ IC Number: _____________________

Date: __________________________ Date: __________________________

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